Question

A nurse in an acute care facility is preparing a discharge summary for a client transferring to a long-term care facility. Which of the following documentation should the nurse include?

a. Detailed medication reconciliation
b. Recent vital signs and lab results
c. Family contact information
d. Admission history and physical

Answer 1

The nurse should include detailed medication reconciliation, recent vital signs and lab results, family contact information, and admission history and physical in the discharge summary.

Step-by-step explanation:

When preparing a discharge summary for a client transferring to a long-term care facility, the nurse should include the following documentation:

1. Detailed medication reconciliation: This is important to ensure the accurate transfer of medication information and prevent medication errors.
2. Recent vital signs and lab results: This provides important information about the client's health status.
3. Family contact information: In case of emergencies or the need for communication, it is important to have the contact information of the client's family.
4. Admission history and physical: This provides an overview of the client's medical history and helps in planning the care in the long-term care facility.